The findings of the on-site investigation, conducted 10/18/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on interview and record review, conducted during a site visit on 10/18/23, it was confirmed the facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST). Findings include, but not limited to:

During an interview on 10/18/23, Staff 1 (Administrator) stated the ABST pulls data from the residents' service plans and updated nightly. Staff 1 stated the 22 ADLs are not individually listed in the tool, or if it was listed s/he did not have access to the report.

A review of Resident 1, Resident 2 and Resident 3s' ABST on 10/18/23, lacked the number of minutes allocated in every ADL as is required. Resident 1's ABST was last updated on 07/12/23, which was not updated quarterly as required.

The findings of the investigation were reviewed with and acknowledged by Staff 1 and Staff 2 (RCC) on 10/18/23.

It was determined the facility failed to fully implement and update the ABST.